Couples Information Form PARTNER 1: INFORMATIONFirst Name *Last Name *Date of 1st Appointment Therapist Gender *Date of Birth *Age * PARTNER 1: MEDICAL HISTORYPrimary Care PhysicianPhysician's Name Physician’s Phone Physician’s Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryMany managed care companies require that we have interaction with the client’s physician to coordinate care. Do you give us consent to discuss your care with the above named doctor? YesNoDate of last medical evaluation Date of next appointment Current medications being takenMedication 1: Dosage/Frequency Start Date Purpose Medication 2: Dosage/Frequency Start Date Purpose Medication 3: Dosage/Frequency Start Date Purpose Medication 4: Dosage/Frequency Start Date Purpose Prescribed by HospitalizationHave you ever been hospitalized for medical or psychiatric reasons? YesNoHospital Date Reason Hospital Date Reason Hospital Date Reason Drug UseDo you use recreational drugs? YesNoIf no, have you used previously? YesNoIf yes, when did you stop? Type of Drug How Much? How Often? Type of Drug How Much? How Often? Type of Drug How Much? How Often? Do you drink alcohol? YesNoIf no, did you drink previously? YesNoIf yes, please list: Type of Alcohol How much? How often? Type of Alcohol How much? How often? Type of Alcohol How much? How often? Do you smoke cigarettes? YesNoDo you use other forms of tobacco? YesNoIf yes, what kind? Describe any important medical history, chronic ailments, or other health problems you experience: Describe any other health problems or important medical history about your immediate family members and close relatives, including chronic ailments: Do you have any close relatives (father, mother, brother, sister, grandparent) who have experienced depression, anxiety, or other emotional difficulties? Please list: PARTNER 1: SCHOOL AND FAMILY HISTORYDid you experience any developmental, academic or behavior problems as a child or while in school, with peers or teachers? YesNoIf yes, please explain What was the last year of school you completed? If you did not complete high school, please explain How would you describe your current support network? (friends, relatives, etc.): Please check all information which applies to your biological parents:Mother livingdeceasedmarrieddivorcedremarriedFather livingdeceasedmarrieddivorcedremarriedIf Mother remarried, how many times? If Father remarried, how many times? Do you consider someone else (step-parent, grandparent, etc.) to be one or both of your “real” parents? If so, whom? Describe your relationship with your mother while growing up: Currently Describe your relationship with your father while growing up: Currently: List first names and ages of brothers & sisters, including yourself:1) Name Age Relationship (biological, step, half...) 2) Name Age Relationship (biological, step, half...) 3) Name Age Relationship (biological, step, half...) 4) Name Age Relationship (biological, step, half...) Describe any family problems which occurred while growing up relating to:Alcohol/drug abuse Sexual/physical/emotional abuse PARTNER 1: MARITAL HISTORYMarital status: Single/Never MarriedMarriedDomestic PartnershipSeparatedDivorcedWidowedIf currently married or in a domestic partnership, for how long? If living w/someone, how long? Please list your children:1) Name Age Relationship Lives with? 2) Name Age Relationship Lives with? 3) Name Age Relationship Lives with? 4) Name Age Relationship Lives with? PARTNER 1: MENTAL STATUSPlease check any of the following that describe how you have been feeling lately: sadanxiousdepressedfrightenedguiltyangryashamedaggressiveresentfulworthlesstearfulirritableconfusedextreme ups/downsjealoushopelesshelplessDescribe any other feelings you have had: What activities or hobbies do you participate in? Do you participate in regular exercise? YesNoDescribe: Describe your current working environment: Have you had any change in sleeping habits? YesNoDescribe: Have you had any change in eating habits? YesNoDescribe: Have you ever considered suicide in connection to your current problem? YesNoIf so, please give a brief description with dates: Have you ever considered suicide in the past? YesNoIf so, please give a brief description with dates: Have you attempted suicide recently or in the past? YesNoIf so, please give a brief description with dates: Have you had any homicidal thoughts recently or in regard to your current problem? YesNoIf yes, please explain: Have you ever considered homicide in the past? YesNoIf yes, please explain: PARTNER 1: LEVEL OF FUNCTIONINGList or describe any current impediments or problems in daily psychological, social or occupational functioning (i.e. isolation from friends/family, significant difficulty getting to work or completing daily tasks, severe financial strain, recent divorce, THOUGHTS: Please check any of the following that apply to you: I sometimes hear voices even though no one nearby is talking to me.I sometimes feel that forces outside of me control me.I sometimes feel that other people control my thoughts.I sometimes have the same thought over and over and cannot control it.I sometimes feel that someone is out to hurt me or do something against me.I am sometimes unable to control my behavior.Please explain: PARTNER 2: INFORMATIONFirst Name *Last Name *Date of 1st Appointment Therapist Date of Birth *Age * PARTNER 2: MEDICAL HISTORYPrimary Care PhysicianPhysician's Name Physician’s Phone Physician’s Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryMany managed care companies require that we have interaction with the client’s physician to coordinate care. Do you give us consent to discuss your care with the above named doctor? YesNoDate of last medical evaluation Date of next appointment Current medications being takenMedication 1: Dosage/Frequency Start Date Purpose Medication 2: Dosage/Frequency Start Date Purpose Medication 3: Dosage/Frequency Start Date Purpose Medication 4: Dosage/Frequency Start Date Purpose Prescribed by HospitalizationHave you ever been hospitalized for medical or psychiatric reasons? YesNoHospital Date Reason Hospital Date Reason Hospital Date Reason Drug UseDo you use recreational drugs? YesNoIf no, have you used previously? YesNoIf yes, when did you stop? Type of Drug How Much? How Often? Type of Drug How Much? How Often? Type of Drug How Much? How Often? Do you drink alcohol? YesNoIf no, did you drink previously? YesNoIf yes, please list: Type of Alcohol How much? How often? Type of Alcohol How much? How often? Type of Alcohol How much? How often? Do you smoke cigarettes? YesNoDo you use other forms of tobacco? YesNoIf yes, what kind? Describe any important medical history, chronic ailments, or other health problems you experience: Describe any other health problems or important medical history about your immediate family members and close relatives, including chronic ailments: Do you have any close relatives (father, mother, brother, sister, grandparent) who have experienced depression, anxiety, or other emotional difficulties? Please list: PARTNER 2: SCHOOL AND FAMILY HISTORYDid you experience any developmental, academic or behavior problems as a child or while in school, with peers or teachers? YesNoIf yes, please explain What was the last year of school you completed? If you did not complete high school, please explain How would you describe your current support network? (friends, relatives, etc.): Please check all information which applies to your biological parents:Mother livingdeceasedmarrieddivorcedremarriedFather livingdeceasedmarrieddivorcedremarriedIf Mother remarried, how many times? If Father remarried, how many times? Do you consider someone else (step-parent, grandparent, etc.) to be one or both of your “real” parents? If so, whom? Describe your relationship with your mother while growing up: Currently Describe your relationship with your father while growing up: Currently: List first names and ages of brothers & sisters, including yourself:1) Name Age Relationship (biological, step, half...) 2) Name Age Relationship (biological, step, half...) 3) Name Age Relationship (biological, step, half...) 4) Name Age Relationship (biological, step, half...) Describe any family problems which occurred while growing up relating to:Alcohol/drug abuse Sexual/physical/emotional abuse PARTNER 2: MARITAL HISTORYMarital status: Single/Never MarriedMarriedDomestic PartnershipSeparatedDivorcedWidowedIf currently married or in a domestic partnership, for how long? If living w/someone, how long? Please list your children:1) Name Age Relationship Lives with? 2) Name Age Relationship Lives with? 3) Name Age Relationship Lives with? 3) Name Age Relationship Lives with? PARTNER 2: MENTAL STATUSPlease check any of the following that describe how you have been feeling lately: sadanxiousdepressedfrightenedguiltyangryashamedaggressiveresentfulworthlesstearfulirritableconfusedextreme ups/downsjealoushopelesshelplessDescribe any other feelings you have had: What activities or hobbies do you participate in? Do you participate in regular exercise? YesNoDescribe: Describe your current working environment: Have you had any change in sleeping habits? YesNoDescribe: Have you had any change in eating habits? YesNoDescribe: Have you ever considered suicide in connection to your current problem? YesNoIf so, please give a brief description with dates: Have you ever considered suicide in the past? YesNoIf so, please give a brief description with dates: Have you attempted suicide recently or in the past? YesnoIf so, please give a brief description with dates: Have you had any homicidal thoughts recently or in regard to your current problem? YesNoIf yes, please explain: Have you ever considered homicide in the past? YesNoIf yes, please explain: PARTNER 2: LEVEL OF FUNCTIONINGList or describe any current impediments or problems in daily psychological, social or occupational functioning (i.e. isolation from friends/family, significant difficulty getting to work or completing daily tasks, severe financial strain, recent divorce, THOUGHTS: Please check any of the following that apply to you: I sometimes hear voices even though no one nearby is talking to me.I sometimes feel that forces outside of me control me.I sometimes feel that other people control my thoughts.I sometimes have the same thought over and over and cannot control it.I sometimes feel that someone is out to hurt me or do something against me.I am sometimes unable to control my behavior.Please explain: OTHER INFOIs there any other information regarding you or your family that you would like to share with your Therapist that is not covered on this form? You may also use this space to complete earlier responses. Please list your therapy goals: THANK YOU! VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
